title: Impact of de-escalation therapy on clinical outcomes for intensive care unit-acquired pneumonia.
abstract: BACKGROUND
  De-escalation therapy is a strategy currently used for the management of nosocomial pneumonia. In this study, we evaluated clinical outcomes and risk factors related to de-escalation therapy in patients with intensive care unit (ICU)-acquired pneumonia.
  
  
  METHODS
  This was a retrospective observational cohort study of ICU patients who developed pneumonia more than 48 hours after admission to the ICU at Samsung Medical Center from September 2004 to December 2007.
  
  
  RESULTS
  The 137 patients comprised 44 (32.1%) who received de-escalation therapy and 93 in the non-de-escalation group. The de-escalation group showed a lower pneumonia-related mortality rate than the non-de-escalation group by day 14 (2.3% vs. 10.8%, respectively; P = 0.08) and by day 30 (2.3% vs. 14%, respectively; P = 0.03) after the diagnosis of pneumonia. The variables independently associated with ICU-acquired pneumonia-related mortality included the Acute Physiology and Chronic Health Evaluation II (APACHE II) score and the modified Clinical Pulmonary Infection Score (CPIS) after 5 days with pneumonia. The non-de-escalation group had significantly higher APACHE II score and modified CPIS after 5 days with ICU-acquired pneumonia compared to the de-escalation group. Among all patients, 20.4% (28 of 137) had negative cultures for pathogens, and 42.9% (12 of 28) received de-escalation therapy. The latter 12 patients received de-escalation therapy and survived 30 days after the diagnosis of pneumonia.
  
  
  CONCLUSIONS
  Patients in the de-escalation group showed a significantly lower mortality rate compared to patients in the non-de-escalation group. De-escalation therapy can be safely provided to patients with ICU-acquired pneumonia if they are clinically stable by day 5, even in those whose respiratory specimen cultures yield no specific pathogens.
authors.affiliation: Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea.
authors.forename: Mi Kyong
authors.initials: MK
authors.lastname: Joung
authors.forename: Jeong-a
authors.initials: JA
authors.lastname: Lee
authors.forename: Soo-Youn
authors.initials: SY
authors.lastname: Moon
authors.forename: Hae Suk
authors.initials: HS
authors.lastname: Cheong
authors.forename: Eun-Jeong
authors.initials: EJ
authors.lastname: Joo
authors.forename: Young-Eun
authors.initials: YE
authors.lastname: Ha
authors.forename: Kyung Mok
authors.initials: KM
authors.lastname: Sohn
authors.forename: Seung Min
authors.initials: SM
authors.lastname: Chung
authors.forename: Gee Young
authors.initials: GY
authors.lastname: Suh
authors.forename: Doo Ryeon
authors.initials: DR
authors.lastname: Chung
authors.forename: Jae-Hoon
authors.initials: JH
authors.lastname: Song
authors.forename: Kyong Ran
authors.initials: KR
authors.lastname: Peck
mesh_terms: D018806:APACHE; D000368:Aged; D000890:Anti-Infective Agents / Q000627:therapeutic use*; D001431:Bacteriological Techniques; D003428:Cross Infection / Q000188:drug therapy* / Q000453:epidemiology / Q000401:mortality; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D018410:Pneumonia, Bacterial / Q000188:drug therapy* / Q000453:epidemiology / Q000401:mortality; D056910:Republic of Korea / Q000453:epidemiology; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000890:Anti-Infective Agents